The Kenya Health Behavior Study: Piloting Results (NIAAA R21AA016884) Rebecca K. Papas, PhD Associate Research Scientist Yale School of Medicine

Kenya Health Behavior Study collaborators Rebecca Papas, Ph.D. David Ayuku, Ph.D. John Sidle, M.D. Otieno Omolo, M.D. Joyce Ballidawa, M.S. Rogers Songole, M.S. Willis Owino-Ong’or, M.D. Claris Ojwang Steven Martino, Ph.D. Stephen Maisto, Ph.D. Kathleen Carroll, Ph.D. Joseph Goulet, Ph.D. Amy Justice, M.D., Ph.D.

Additional acknowledgments Kendall Bryant, PhD Chematics, Inc. Indiana University School of Informatics Funded by: National Institute on Alcohol Abuse and Alcoholism (R21AA01688) No commercial conflict of interest

Alcohol in Kenya Hazardous drinking in Eldoret 68% general medicine patients 53% HIV patients Traditional brew (illegal) 54% rural Eldoret patients 21% town Eldoret patients Adverse medical outcomes for HIV infected Dose-response relationship Shaffer et al., 2004; Justice et al., 2006

HIV prevalence and risk in Africa 2/3 worldwide cases found in sub-Saharan Africa 5.1% prevalence in Kenya ~10% condom use among HIV patients Women Men Adults 6.7% 3.5% Young people (ages 15-25) 4.5% 0.8% National AIDS Control Council Kenya, 2007

In line for the latest batch of chang’aa (spirits)

Kenya Health Behavior Study goals I. Culturally adapt behavioral treatment to reduce alcohol use for group paraprofessional delivery and adapt methods to Kenyan cultural context II. Determine feasibility through piloting III. Conduct a small randomized clinical trial of cognitive behavioral treatment compared to existing HIV support group

AMPATH Patients in HIV care (n = 65,000) Electronic medical records 50% on ARVs Electronic medical records Full reference laboratory Comprehensive approach Food “prescriptions”

Goal I: Cultural adaptation tasks 1. Translate/adapt Kiswahili survey 2. Estimate alcohol content of traditional brew 3. Tailor intervention to cultural context 4. Train group facilitators

Busaa (“maize beer”) is fermented from rotting maize flour and yeast made from millet

Chang’aa (spirits) are distilled from busaa waste and from sugar

Serving sizes of chang’aa

Busaa is sold in larger serving sizes

Goal II: Determine Feasibility Through Piloting: Methods and Results

Methods: Pilot groups Build facilitator skills Hone treatment manual 6 session CBT Inclusion criteria HIV clinical patients Any alcohol in past month English or Swahili speaking One hour travel time No plans to move within next 8 weeks

Results: Pilot groups N=5 (3 for women, 2 for men) Retention: Men 76%, Women 78% (those who attended ≥1 session, n=27) 14 individuals did not attend any sessions Withdrawal symptoms Brewers and barmaids

Treatment Attenders: Group Characteristics, Retention and Size

Reasons for Nonattendance Never showed Thought would result in job training (1m) Could not be reached (3f, 3m) Thought videotaping would be made public (1f) Missed sessions Childcare-related issues (1m, 1f) Psychiatric hospitalization (1f) Psychiatric evaluation (1f) Drank alcohol before session (3f, 2m) Pre-treatment procedure took too long (1f) Thought detox meds were harmful (1f) Work conflict (2f, 1m)

Next steps Stage 1 Randomized Clinical Trial 56 HIV-infected patients (50% women) ARV-eligible or initiated on ARVs in past 12 months 6 CBT group sessions compared to HIV support In Kiswahili Yale Adherence and Competence Scale ratings Survey test-retest reliability

Addressing retention challenges Letter to employer about treatment Phone reminders and follow-up Increased staff size Transport provided to 1st CBT session 10-minute problem-solving checklist

Overview of Randomized Clinical Trial

Questions?